Sociodemographic characteristics of the participants are provided in Table 1. Most participants were 40 years old or younger (65%) and there was a roughly equal proportion of men (47%) and women (53%). The sample was racially diverse, with 47% identifying as White, 35% identifying as Black, and 12% identifying as Asian. The majority identified as non-Hispanic (71%). Notably, 35% of participants had lived experience with injection drug use and 88% of participants had at least five years of experience working with PWID. The leadership status of participants within the organization was categorized according to the CFIR construct definitions, with 18% of participants categorized as high-level leaders, defined as “Individuals with a high level of authority, including key decision-makers, executive leaders, or directors,” 29% categorized as mid-level leaders, or “Individuals with a moderate level of authority, including leaders supervised by a high-level leader and who supervise others,” and 53% were other cadres of employees (39). Specific roles within the organization varied, including peer navigators/outreach workers (35%), clinicians (29%), researchers (18%), administration (12%), and phlebotomists (6%).
Table 1
Sociodemographic characteristics of participants
Sociodemographic characteristic | N (%) |
Age (years) | |
| 21–30 | 3 (18) |
| 31–40 | 8 (47) |
| 41–50 | 2 (12) |
| 51–60 | 2 (12) |
| 61–70 | 2 (12) |
Sex | |
| Male | 8 (47) |
| Female | 9 (53) |
Race | |
| Black | 6 (35) |
| White | 8 (47) |
| Asian | 2 (12) |
| Other | 1 (6) |
Ethnicity | |
| Hispanic | 5 (29) |
| Non-Hispanic | 12 (71) |
Lived experience | 6 (35) |
Years working on issues affecting PWID | |
| < 5 | 2 (12) |
| 5–10 | 8 (47) |
| > 10 | 7 (41) |
Leadership level | |
| High-level leader | 3 (18) |
| Mid-level leader | 5 (29) |
| Other | 9 (53) |
Specific role in the SSP | |
| Administration | 2 (12) |
| Clinician | 5 (29) |
| Phlebotomist | 1 (6) |
| Researcher | 3 (18) |
| Community Engagement | 6 (35) |
Table 1. Sociodemographic characteristics of participants
Facilitators and barriers to the implementation of COVID-19 vaccines at the SSP were identified in each of the five CFIR domains: Innovation, Outer Setting, Inner Setting, Individual Characteristics, and Implementation Process (Table 2).
Table 2
Themes and exemplar quotes, by CFIR domain and construct
CFIR Domain | CFIR Construct | Theme | Exemplar Quote |
Innovation | Evidence-base | Facilitators | Evidence of the COVID-19 vaccines’ effectiveness | I think the vaccine is effective for preventing severe illness and death from COVID. |
Complexity | Barriers | Storage and management requirements of the COVID-19 vaccines | We need to make sure that the refrigerator is monitored, and the temperature doesn’t go up or down too drastically. |
Outer Setting | Partnerships and connections | Facilitators | Established partnership with the Department of Health | The public servants at the Department of Health have always been very supportive of the type of work that we do. |
Financing | Existing funding that could be leveraged to support COVID-19 vaccine-associated costs | We could order [the vaccine] for free from the Florida Department of Health. |
Local attitudes | Barriers | Politicization of the COVID-19 vaccines | [Specific public officials] were at [the SSP] but we didn't mention our COVID vaccination partnership because of the non-belief in vaccines from the political appointees. |
Policies and laws | Policies governing vaccine storage, management, and administration | You have to be a medical assistant or a nurse or a doctor to administer the vaccines…it’s against the law for me to give vaccine. |
Inner Setting | Recipient-centered culture | Facilitators | Established foundation of trust between the SSP and PWID | We meet them where they're at, regardless of what they're doing, how they're doing, with a level of love and care, which creates a trust factor. |
Mission alignment | Alignment with organizational goal of serving as a “one-stop-shop" | They can access everything. It’s a one-stop shop here. I think that makes it easier for them. |
Compatibility | Existing services and research studies for alignment and/or integration | The COVID-19 vaccine could be offered alongside “[syringe] exchange,” at the weekly “health clinic,” or on the “mobile unit” |
Tension for change | Consensus about the need for new approaches to reach PWID with the COVID-19 vaccines, and the relative advantage of doing so through the SSP | We tend to provide things to people in a setting that is as comfortable as possible for them… It doesn’t look like a clinical setting with people looking down at them. |
Relative priority | Barriers | Competing organizational priorities | [The COVID-19 vaccine initiative] is not something as staff that is on the top of our agenda. |
Available resources | Personnel shortages | We need more people because one person can't be at 10 places. |
Relational connections | Segmentation of roles and responsibilities | Everyone has their tasks that they need to hit, so maybe sometimes that kinda gets in the way of being a little more, I guess, well-rounded. |
Communications | Limited internal staff communication across services/research studies | A lot of us don't know half of what's really going on, research studies or things being implemented. |
Individual Characteristics | High-level leaders | Facilitators | Influential decision-makers | Have you heard the Ariana Grande song? ‘I want it, I got it.’ I want it, so… [laughter]. |
Implementation leads, Motivation | A clear champion | It took “the self-efficacy of one person [to get] everything done." |
Other implementation support | Barriers | Lack of ownership among staff members not directly involved in delivery of the vaccines | Personally, I don’t feel, like, very responsible, or...that involved in, like, making it a success. |
Innovation deliverers, Capability | Limited personnel with the technical skills to manage and administer the vaccines | Since there’s only one person that can do it, if he’s not here, then that means...they can’t get it. That happens pretty frequently. |
Innovation recipients, Opportunity | Higher order needs | The biggest thing is just the competing survival, mental health, and the substance use disorder. Our participants, as soon as there's a barrier it feels unsurmountable. |
Innovation recipients, Motivation | Limited perceived susceptibility to COVID-19 | Many PWID don’t believe that COVID-19 “could cause them any damage, because of where they're at in their own lives. |
Misinformation about COVID-19 and the COVID-19 vaccines | Most people have a conspiracy theory idea behind COVID. They’re tryin’ to microchip us, or…that they’re tryin’ to wipe all the HIV positive people out. |
Implementation Process | Doing | Facilitators | Adaptive and flexible approach to implementation | At [our SSP], we’re always making changes and always adapting. I think like every week it’s something new or something different. |
Engaging innovation recipients | Transparent and consistent communication about the COVID-19 vaccines with PWID | We don't force it. We tell them whatever they’re more comfortable with and remind them that we’ll always have vaccines available on site if they choose, later on. |
Engaging innovation deliverers | Barriers | Limited internal staff communication about the COVID-19 vaccines | I haven’t gotten any updates about whether or not it’s progressing or whether or not they needed to find more people. That coordination piece, I have not seen. |
Teaming | Limited involvement of the peer navigators/outreach workers and the mobile unit | Definitely [the peer navigators/outreach workers], they could communicate. Since they handle a lot of participant's medications, that's also a sense of trust there that they develop with the participants. |
Adapting | Tension between increasing vaccine uptake and reducing waste | Before when it started, we would...schedule around maybe six until those six would come. Now if only one comes or two show up, we’ll administer that to just that one or two, rather than wait for those six. We’ll just discard the rest. |
Assessing needs of innovation recipients | Lack of compensation | Pay them for their time...That takes away the competing priority. They don't have to hustle for that half hour. They can follow through on what they want to for their health. |
Innovation
Facilitators
There was consensus among all staff members that the strong evidence supporting the innovation – i.e., COVID-19 vaccines – was an important facilitator for its implementation. As one staff member said, “The vaccine is effective for preventing severe illness and death from COVID. It’s for definite outcomes that are relevant to our participants.” Another staff member remarked that there were clear “advantages of being vaccinated as opposed to not being vaccinated.”
Barriers
On the other hand, the complexity of the COVID-19 vaccines’ storage and management created challenges for implementation. As one staff member explained, “There are considerations for the storage and the temperatures, and how long the vaccine can be reconstituted.”
Outer Setting
Facilitators
Staff members, especially high-level leaders, emphasized that existing relationships and collaborations between the SSP and external partners, especially the Department of Health, were crucial facilitators to the implementation of the COVID-19 vaccine at the SSP. As one staff member stated, “The public servants at the DOH have always been very supportive of the type of work that we do.” Another staff member explained, “They’re the ones supplying the COVID vaccines to us."
Staff members also described the importance of the SSP’s existing funding sources that could be leveraged to cover COVID-19 vaccine-associated costs. Although the SSP could “order [the vaccine] for free from the Florida Department of Health,” there were other upfront and ongoing costs, including purchasing new physical infrastructure for storage and hiring new personnel with the technical skills to administer them. Continued the same staff member, “There's no funding to support our COVID vaccination. We wrapped it in with our research and other contracts as we always do.”
Barriers
Multiple staff members described the COVID-19 vaccines’ storage and management policies as a barrier to implementation. Before the Department of Health dispersed vaccines to the site, the SSP had to demonstrate that it was “set up with [the capabilities]” to meet the requirements, which required procurement of new infrastructure (e.g., refrigeration systems) and creation of new operating procedures. Likewise, policies regarding vaccine administration credentials necessitated the hiring of new staff members. As one participant explained, “It’s against the law for me to give vaccine”, “you have to be a medical assistant or a nurse or a doctor to administer the vaccines.”
Table 2: Themes and exemplar quotes, by CFIR domain and construct
Additionally, a few staff members cited the political climate in Florida as another implementation barrier. Said one, “[Public officials] were at [the SSP] but we didn't mention our COVID vaccine partnership because of the non-belief in vaccines from the political appointees.” On the other hand, the same staff member hypothesized that offering vaccines at the SSP could expand support for SSPs among those opposed to their core purpose of syringe exchange:
I think it's very important particularly in a conservative state like Florida to show that we are offering well beyond syringes for the injection of drugs. If we did more reporting surrounding the number of touch points that we have providing people medications for opioid use disorder, HIV meds, COVID vaccination. If that's the way they want harm reduction packaged.
Inner Setting
Facilitators
Staff members described four characteristics of the SSP’s inner setting favorable to the implementation of the COVID-19 vaccines. First and foremost is the established foundation of trust that the SSP has with PWID. As one staff member explained:
They've seen us the whole way through. They saw us when we were fighting for needle exchange. They saw us win. They saw us implement, and they saw it grow. Then they saw us make it legal in the whole state. They trust us. They trust that we have their best interest.
They emphasized that this trust was especially important with the COVID-19 vaccine, given their misinformation and politicization. Said one, “If anybody's gonna change [PWID’s distrust of the COVID-19 vaccine], it is us.” Said another, “They understand that…[we] would never…inject them with something that I would not inject myself with…What we do at [the SSP] is…held to a standard of what we would do for our own family.” A third expanded:
We meet them where they're at, regardless of what they're doing, how they're doing, with a level of love and care, which creates a trust factor with them to where they may be able to say, “This is why I don't want to be vaccinated”…I think because of who we are…[we can] shift their thinking about whether or not this is good for them.
Second, staff members described that the SSP’s non-judgmental and non-stigmatizing setting and its culture of meeting PWID’s evolving needs with love and respect gave it an indisputable relative advantage compared to other healthcare settings. “To be honest, our participants hate every other place” said one staff member; explained another, “they have a hard time even going into Walgreens without being stared at.” In contrast, “We tend to provide things to people in a setting that is as comfortable as possible for them… It doesn’t look like a clinical setting with people looking down at them." Another expanded, “The doctors down to the people who are the security guard at the front…have a level of cultural competence for people who inject drugs that really they don’t get anywhere else in Miami.”
Third, offering COVID-19 vaccines at the SSP aligned with the organization’s mission and its staff’s motivation to serve as a “one-stop-shop” for its clients. “They can pick up their medication. They can do an exchange. They can access everything. It’s a one-stop shop here.” Said another, “Since they're already here, I think that's definitely an advantage...they don't have to go out of their way or go to visit or wait anywhere. You know, they just really don't have that kind of time.”
Finally, implementation of the COVID-19 vaccine was compatible with the existing services and research studies at the SSP. Staff mentioned that the COVID-19 vaccine could be offered alongside “syringe exchange,” at the weekly “health clinic,” or on the “mobile unit” for clients who don’t come to the fixed site. One staff member mentioned that it could be integrated into an ongoing study regarding the influenza vaccine. Another noted that vaccination records could be “connected to their [SSP enrollment] number” in the SSP’s database, reported in the team’s “weekly email,” and discussed at the team’s weekly meeting to facilitate monitoring and evaluation.
Barriers
There was a sense among staff members that the COVID-19 vaccine initiative had lower relative priority within the organization as compared to other services. They explained, the COVID-19 vaccine initiative “is not something as staff that is on the top of our agenda” partly because staff members are “probably too busy [with their existing responsibilities] to be involved.” This barrier was exacerbated by personnel shortages: said one, “We’re short-staffed. People work on multiple different studies;” said another, “We need more people because one person can't be at 10 places.”
Additionally, staff members noted that while some “people have sort of fluid roles,” collaboration on the COVID-19 vaccine initiative was limited by the segmentation of staff roles and responsibilities based on existing services and research studies. One staff member explained, “I might not be aware that we're involved. I don't know. I'm always in the van. I don't know what's told at [the peer navigators/outreach workers’ team meeting]…there's not a lotta time for dialog.” Said another:
Everyone has their tasks that they need to hit, so maybe sometimes that kinda gets in the way of being a little more, I guess, well-rounded with the information. You may focus on what you need to get done rather than maybe, oh, this person actually does qualify for a list of things.
Finally, some staff members expressed a need for improved communication at the SSP, in general. They explained, “There's so much going on here” and “a lot of us don't know half of [the] research studies or things being implemented. It would be good to have…something that we could go look at,” such as a “schematic [describing] ‘Here’s this study. It hasn’t started. Here’s the person in charge of it.’”
Individual Characteristics
Facilitators
Staff members noted that the high-level leaders of the SSP serve as the organization’s primary decision-makers, which facilitated prompt implementation of the COVID-19 vaccines at the SSP once they became available. One high-level leader acknowledged the scope of their influence, stating jokingly “Have you heard the Ariana Grande song? ‘I want it, I got it.’ I want it, so… [laughter].” While such decision-making structures can have disadvantages, there was consensus among staff members that the high-level leaders had the capability and expertise to exercise this influence, as well as a clear motivation “to make sure [PWID] are protected.”
Additionally, staff members identified an implementation leader whose capabilities and motivation were critical to the success of the COVID-19 vaccine initiative. This individual had sufficient experience at the SSP to understand its operational dynamics and had the relevant capabilities – a graduate education in science, “great communicator,” “great at interacting with our participants” – to carry out her roles and responsibilities. As one staff member explained, “If we wanted to effect change on the COVID vaccination, we would ask [her], and [she] would execute. She would get it done.”
Barriers
Though the high levels of self-efficacy and motivation among the high-level leaders and the implementation lead were important facilitators, staff members described a lack of other implementation support in the organization. Individuals whose roles were not directly involved with the COVID-19 vaccines expressed a lack of perceived responsibility. As one staff member said, “Personally, I don’t feel, like, very responsible, or, like…I’m that involved in, like, making it a success.”
While personnel shortages were noted as an overarching barrier in the SSP’s Inner Setting, implementation of the COVID-19 vaccines posed particular staffing challenges given the capability requirements for innovation deliverers, i.e., those administering the vaccines. As one staff member explained, “We had [to get] a medical assistant who could administer vaccines.” Even after the medical assistant was hired, multiple staff members still cited the need for additional personnel to ensure sufficient availability of the vaccine: said one, "Since there’s only one person that can do it, if he’s not here, then that means whoever was scheduled for that day, they can’t get it. That happens pretty frequently."
Meanwhile, with regard to characteristics of innovation recipients (i.e., PWID), staff members described limited motivation to get the vaccine as a major barrier to its success. Two reasons were hypothesized for this lack of motivation. First, staff observed widespread misinformation among PWID regarding COVID-19 and the COVID-19 vaccines. “Most people have a conspiracy theory idea behind COVID,” for example, that “they’re tryin’ to microchip us, or…that they’re tryin’ to wipe all the HIV positive people out.” Another described, “There's a lot of different speculation, or just not really believing that it would work or that it may be a government thing.” Staff members attributed this misinformation, in part, to the communication platforms utilized by PWID. Given that “many of our participants are using informal networks to get information, both social media and just word of mouth,” staff noted that “rumors can spread very fast. It can be a problem.” Second, staff described a lack of perceived susceptibility among PWID to COVID-19. Many PWID don’t believe that COVID-19 “could cause them any damage, because of where they're at in their own lives.” Another said, “I don’t think they see…being protected against COVID as an immediate benefit.” Even among PWID who “are immunocompromised, it's still difficult for them to say okay, maybe I should [get vaccinated].” However, one staff member recounted that this was not universally true for all PWID: “I definitely remember speaking with some participants who…see the benefit of it.”
Finally, nearly all the staff members described how PWID’s prioritization of their higher-order needs limited their opportunity to get the COVID-19 vaccine. As one stated, COVID-19 is “one of the last things that they're concerned about.” Explained another:
The biggest thing is just the competing survival, mental health, and the substance use disorder. Our participants, as soon as there's a barrier it feels unsurmountable. They will often not be able to follow through on what—something that they might want to do.
Implementation Process
Facilitators
Staff members described the SSP’s adaptive, flexible, and "organic" culture as a facilitator to the implementation of the COVID-19 vaccines. One high-level leader reflected that the SSP “[improvises] as things come in front of us…Often, we figure it out as we go.” Explained another staff member, “At [the SSP], we’re always making changes and always adapting. I think like every week it’s something new or something different.”
Additionally, staff members highlighted how the SSP’s harm reduction approach to substance use influenced the implementation of COVID-19 vaccines. Staff members explained that, on the one hand, “[We’re] shooting down all of the stuff that they talk about online, showing the advantages as opposed to the disadvantages to having it.” At the same time, though, “We let them choose. We don't force it. We tell them whatever they’re more comfortable with and remind them that we’ll always have vaccines available on site if they choose, later on, to be administrated.”
Barriers
Staff members described four barriers in the COVID-19 vaccines’ implementation process. First, they underscored the need for improved internal staff communication about the COVID-19 vaccines. Specifically, they requested evidence-based information about COVID-19 and the COVID-19 vaccines to guide their conversations with PWID. Additionally, they requested periodic updates about the status of the COVID-19 vaccine initiative to improve their understanding of its strengths and weaknesses. One staff member lamented, “I haven’t gotten any updates about whether or not it’s progressing or whether or not they needed to find more people.”
Second, staff members described the need for improved collaboration with PWID-facing staff, such as the SSP’s outreach workers and peer navigators i.e., people with similar lived experience as the SSP’s clients. They “see these things in the algorithm that we don't see,” one of the high-level leaders reflected. They also “come directly in contact with the participants more so than anybody else” and thus “they have the relationship.” Likewise, they suggested utilizing the SSP’s mobile unit to increase the availability of the vaccine for PWID who don’t come to the SSP’s fixed site and to “get the word out more on the street.”
Third, staff members described the struggle to balance maximizing availability of the vaccines with reducing waste. Because of the vaccines’ technical requirements, once a vial was opened the SSP “only [had] a certain amount of time to use it before it has to be wasted.” Thus, at the beginning, the SSP attempted to schedule vaccine appointments so that multiple PWID would receive the vaccine on certain days. However, staff members agreed that these scheduled appointments limited vaccine uptake and were in conflict with the SSP’s general drop-in approach to service provision. They explained, “[We have to] make it flexible." “When you have them, and you have their attention, you really need to try to work within that time to do as much as you can do to help them. Because they are just trying to survive.”
Finally, all staff members agreed that the lack of compensation was a primary barrier to increasing uptake of the COVID-19 vaccine. Said one staff member, “the participants that are willing to get vaccinated have already been vaccinated." The rest "don’t see the necessity [of it], so if we’re not compensating them, they don’t think they need it.” Further, staff members felt that compensation would be fair to offset the opportunity cost for PWID. As one argued, “Pay them for their time…That takes away the competing priority. They don't have to hustle for that half hour. They can follow through on what they want to for their health.”